Anal Canal

• Length= 3.8 to 4.0 cm

• Zona Columnaris: Upper V2- lined by Simple columnar

• Zona Hemorrhagica: Upper part of lower half ( above the

Hilton'swhite line) - Stratified squamous non-keratinizing
epithelium

Zona Cutanea: Lower part of lower half( below the Hilton's

white line)- Stratified squamous keratinizing epithelium
Anorectal Bundle or Ring:
Demarcating Line B/W the Rectum
& Anal Canal.

Can be felt Posteriorly-Thickened

Ridge

Formed by- Puborectalis, Deep Ext

Sphicter,Conjoined long Muscle &
Internal Sphincter

The disposition of the puborectalis muscle.

Fig. 61.2
Note how it maintains the rectoanai angle.
Puborectalis Muscle: Puborectalis
• Maintain the angle b/w rectum &
anal canal

• Gives off fiber to the

longitudinal muscle layer.
Pubic

• Position, Length as well as angle symphysis

Rectum

of the anorectal Junction - integrity & Coccyx

strength of the Puborectalis muscle Puborectalis

sling. Wall of anal canal

Development of Anal Canal
• Fusion of Post-allantoic gut ( upper) with the
Proctodeum( lower part)
Pectinate or Dentate line is the junction of these two.

• Anal valves of Ball - Remnants of the proctodeal

membrane

Column of Morgagni- Mucosa at dentate line folded in

longitudinal column.
 Rpctal
mucosa
anal sinus
anal valve
Column* of Remnanats of
Levator Morgagni
am muscle Proctodeal M.

Lutcmal j -jl
sphincter muscle

Internal anal Dentate

sphincter muscle (pectinate)

Pectinate line
Anal verge
or margin (dentate line)
(Hilton’s line)
Squamous
mucosa
Image of Anal Sphincter:
Superior fasoa of petvc diaphragm
Inferior fascia of
c*iv« diaphragm
Circular
muscles of
Levator ani rnuscae Rectum

Deep External
Longitudinal
Sphincter.
muscle of
Conjoined Rectum
intemai rectal venous pexu*
longitudinal
muscle
Internal anal S
Uuacutua tu&m.ucoaae am

septum o' achaorectai ~'!n;*rrr.u»Cutar groove

<**■ te tire of Hiton)
Sub cutaneous
External Sphincter External '~Z'3 ,enous c e x u s
Comugator cute am musce
External & Internal Sphincter:
External Sphincter Internal Sphincter

Muscle Single muscle k/as Goligher Muscle Continue of the Circular muscular coat of the
rectum

Color Red Pearly white

Nerve Pudendal Nerve

Autonomic nervous system-Intrinsic non-
adrenergic & noncholinergic fiber
Types of Muscle Somatic Voluntary Muscle Non-striated Involuntary Muscle

Parts/fts Deep, Superficial and Subcutaneous Always lie in the tonic state of contraction
portion
Blood Supply of Anal Canal
• Superior Rectal Artery Right & Left Branch

• Middle Rectal Artery

. '

• Inferior Rectal Artery

Inferior rectal artery

Inferior. R.A
 Upper Half - Superior Rectal Vein IMV Porto mesenteric
venous system
- Middle rectal vein Internal Iliac Vein

Lower Half- Inferior rectal vein & Subcutaneous peri -anal

plexus of veins Internal Iliac Vein

Lymphatic Drainage:
Upper Half- Post Rectal LN Para aortic nodes

Lower Half- Superficial Deep Inguinal LN

Venous system of Anal Canal:
SUPERIOR RECTAL
VEIN

MIDDLE RECTAL
VEIN

INFERIOR
RECTAL VEIN
 Above the dentate line Below the dentate line

Development Post-allantoic gut Proctodeum

Epithelium Cuboidal/Columnar Squamous without sweat & hair

gland
Name Surgical anal canal Anatomical anal canal

Color Pink Skin Colour

Nerve Parasympathetic: painless Spinal nerves: very painful

Venous Portal System Systemic-Ext iliac vein Drainage

Lymphatic Para-aortic Superficial & Deep inguinal LN
Drainage
Examination of Anal Canal:
• Relaxed Patient

• Informed Consent

• Private environment

• Good Light
• Position - Left Lateral Position/ Sims’s Position- most
commonly used.
■vvvvvvvvw-

or dif

Knee elbow posi tion

www.shutterstock.com 78132178
Sim's position
 Patient complaints of :
• dull perianal discomfort and pruritus

• exacerbated by movement and increased perineal

pressure from sitting or defecation

• present with swelling around the rectum

• perirectal drainage that may be bloody, purulent, or

mucoid

( note: ischiorectal abscess often present with systemic

fevers, chills, and severe perirectal pain)
 On examination:
• normal vital signs on initial evaluation

• Physical examination: a small, erythematous,

well-defined, fluctuant, subcutaneous mass
near the anal orifice

DRE: a fluctuant, indurated mass may be

encountered
PeriAnal Abscess
 Differential diagnosis
Likely Diagnosis of Anorectal Pain
Pain Alone Pain and Lump Pain and Bleeding
Pain with Lump
and Bleeding
• Anal Fissure • Perianal Hematoma • Anal Fissure • Hemorrhoids
• Anusitis • Strangulated • Proctitis • Ulcerated
• Ulcerative Proctitis Internal Hemorrhoid Perianal
• Proctalgia Fugax • Abscess Hematoma
• Pilonidal Sinus

Pain, bleeding, Pain with Lump, Pus Pain with Lump, Pus Pain with
with/without Pus Draining, Draining, and Bleeding Lump, Pus
Draining with/without Draining,
Bleeding Bleeding, and
Necrotic Tissue

Perianal Crohn's Hidradenitis Fistula-in-Ano Fournier's

Disease Suppurativa Perianal Tumors Gangrene
 Hemorrhoids
PILONIDAL DSE
Anal Pain
History of Fever
constipation/chronic,
heavy lifting.
Hair-containing
Hematochezzia Abscess (Intergluteal Region)
Purulent Drainage
Mass
Perianal Pain
Skin Tag
Tenderness

ANAL / P ERIANAL
TUMORS
Perianal
Hematoma
Anal Pain Weight Loss
Perianal Pain
History of strained
Perianal Itching
bowel movement,
recent heavy lifting, or Tenesmus
coughing. Purulent Drainage
Perianal Hematoma Bleeding
Mass
Nonhealing Ulceration
Fissure-in-Ano vwwww

Constipation Ulcerative Proctitis

Diarrhea Anal Pain/Tenesmus/
Tenderness
Tearing Pain Ulcers
Tenderness
Fistula
Hematochezzia
Abdonninal Pain
Skin Tag
Voimiting Bloody
Ulceration
Diarrhea

Fournier's Gangrene Perianal Abscess/

Necrosis Fistula-in-Ano
Anal/Perianal Pain
Purulent Drainage Anal/Perianal Itching
Anal/Perianal Pain Swelling
Tenderness Tenesmus Tenderness
Sepsis Abscess
Tenesmus
Immunocompromised
Fever
Sepsis

Fistula Formation
 Workup/Investigations :
• CBC with differential : may show leukocytosis
• Pus cultures
• Blood cultures
• confirmation by means of anal
ultrasonography, CT or MRI
• Plain x-rays little clinical significance
 Anorectal Abscess
infection arising in the cryptoglandular
epithelium lining the anal canal
Squamocolumnar \
Junction A Rectum

Anal Columns
of Morgagni

Pectinate or
Dentate Line

Internal
Sphincter Muscle

Anal Crypt

Anal Gland

44
m fu
CC
<< U"M

Sweat Glands and nal Verge Anoderm External

Hairs in Perianal Skin Sphincter Muscle
 Anatomy review
Arteries: Veins:
From interior mesentenc artery To portal venous system

Nerves:- Lymphatics:
■ Visceral motor (mixed To internal iliac
sympathetic and lymph nodes
parasympathetic) and
sensory innervation

Pectinate line
Pectinate line

To superficial
■ Somatic motor and —
inguinal lymph
sensory innervation
nodes
From internal iliac artery To caval venous system

Separation of •visceral" and *parietal" at the pectinate

Types /classification
1. Perianal (60%) :of suppuration in an anal
gland
2. Ischorectal (30%): extension laterally
through the external sphincter
3. Submucous
4. Pelvirectal : situated between the upper
surface of the levator ani and the pelvic
penitoneum
5. Fissure abscess
 Classification

Supralevator ■

Levator ani
muscle

Ischioanal (ischiorectal)
Perianal Internal (
External abscess
abscess sphincter
Intersphincteric (intramuscular

or submucosal) abscess
 Etiology
• Non specific :Cryptoglandular in origin.

• Specific:
1. Infection : E.coli, Staph. , strep. , Bacteroids
2. Irritation : Crohn's disease, ulcerative colitis, FB
3. Immune compromised state : DM,AIDS,malignancy
4. Others : TB, STDs, Radiation therapy,
 PATHOPHYSIOLOGY

Originates from an infection arising in the crypto glandular

epithelium lining the anal canal

The internal anal sphincter normally serves as a

barrier to infection passing from the gut lumen
to the deep perirectal tissues.

This barrier can be breached through the

crypts of Morgagni, which can penetrate
through the internal sphincter into the
intersphincteric space
 PATHOPHYSIOLOGY

Once infection gains access to the intersphincteric space, it has easy

access to the adjacent perirectal spaces

Extension of the infection can involve the intersphinteric space

2-5%, ischiorectal space 20-25%, or even the supralevator space
2,5%
 Epidemology
• May resolve itself
• Third and fourth decades of life
• Quite common in infants too
• Men are affected more frequently than
women 2:1 - 3:1
• Relation between the formation of ano-
rectal abscesses and bowel habits
 Management
• Early surgical drainage of the purulent
collection
• Primary antibiotic therapy alone is
ineffective
• Any delay : augments tissue damage, may
impair sphincter continence function,
promote stricture and/or fistula formation
• Ability to drain an anorectal abscess
depends on patient comfort and on the
location and accessibility of abscess.
 Drainage of perianal or superficial
abscesses
A small cruciate incision is made over the area of fluctuancy in
close proximity to the anal verge.

Pus is collected and sent for culture. Hemostasis is achieved with

manual pressure, and the wound is packed with iodophor gauze.

The gauze is removed after 24 hours, and the patient is instructed to

take sitz baths 3 times a day and after bowel movements.
 Post operative
• Analgesics and stool softeners are prescribed
to relieve pain and prevent constipation.

• Antibiotic therapy when indicated- to cover

aerobes and anaerobes e.g. ciprofloxacin 500
mg PO 2x daily for 5 days

• Follow up: 2-3 weeks for wound evaluation

and inspection for possible fistula-in-ano.
 COMPLICATIONS

Fistula-in-Ano
Fournier’s Gangrene
Death

Carcinoma Fecal
Incontinence
 Fistula in ano
• a communication between an internal
opening in the anal canal and an external
opening through which an abscess drained
Klasifikasi Fistula Perianal
Berdasarkan lokasi internal opening (2):

- Fistula letak rendah dimana internal

opening fistel ke anus terdapat di bawah
cincin anorektal. Fistula letak rendah dapat
dibuka tanpa takut adanya resiko
inkontinensia permanen akibat kerusakan
bundle anorektal.

- Fistula letak tinggi dimana internal opening

fistel ke anus terdapat di atas cincin
anorektal. Pada fistula letak tinggi dilakukan
koreksi bertahap dengan prosedur operasi
yang lebih sulit.
 Park’s Classification

Intersphincteric fistula
Transsphincteric fistula
Suprasphincteric fistula
Extrasphincteric fistula
 History

• previous history of anorectal suppuration

• intermittent or persistent purulent or
serosanguineous drainage from an external
opening in the perianal area.
• Pruritic symptoms may be present
 Examination
• Perianal examination
• DRE
• Anoscopy
 Evaluation of Anal Fistula
• An accurate preoperative assessment of the anatomy of an anal
fistula is very important.

• Five essential points of a clinical examination of an anal fistula :

(1) location of the internal opening.
(2) location of the external opening.
(3) location of the primary track .
(4) location of any secondary track.
(5) determination of the presence or absence of underlying
disease .
Goodsall's rule
 Special Studies

• Sigmoidoscopy and Colonoscopy

• all patients with anorectal fistulas
• presence of associated pathology such
as :
> neoplasms,
> inflammatory bowel disease,
> associated secondary tracts
 Fistulography
• with recurrent fistulas or
• when a prior procedure has failed to identify
the internal opening

• useful in identifying unsuspected pathology,

planning surgical management, and
demonstrating anatomic relations.
 Anorectal Ultrasonography

• For anatomy of the anal sphincters in relation

to an abscess or a fistula.
• 7-or 10-MHz transducer
• Fistula tracts and abscesses appear as
hypoechoic defects within the muscle.
• extrasphincteric, and suprasphincteric tracts
may be missed.
• hydrogen peroxide injected into fistulas is safe,
effective, and more accurate than conventional
transanal ultrasound
Intersphincteric
abscess
 Magnetic Resonance Imaging
• for anatomy
• chronic or recurrent fistula
• saline solution as a contrast agent
• gadolinium enema: enhanced T2 images and
improved lesion identification

• Computed Tomography:
• Limited due to poor visualization of the
levators and sphincter complex.
• For assessment of associated pelvic pathology
 Anorectal Manometry
• assist in identifying patients at the risk for
postoperative incontinence.
• Surgical management can be tailored accordingly,
improving clinical and functional outcome.

Indications:
• suspected sphincter impairment;
• needing substantial portions of the external sphincter
divided for fistula cure;
• women with a history of multiparity, forceps delivery,
third-degree perineal tear, high birthweight, or
prolonged second stage of labor.
 Fistuloscopy

• intraoperative technique to identify primary

fistula openings, multiple or complex tracts,
and iatrogenic tracts
 MANAGEMENT

The principles are:

1. Identification of the primary opening.

2. Relationship to puborectalis
3. Least amount of muscles should be divided.
4. Side tracts should be sought,
5. Presence of underlying disease.
TREATMENT

• The treatment of anal fistula is dictated by the

classification and the amount of sphincter complex that
is involved with the tract.
• Simple fistulas, intersphincteric, and low trans-
sphincteric of cryptoglandular origin, can be treated
easily with a fistulotomy with minimal risk to continence
• Complex fistulas, high fistulas, and those related to
inflammatory bowel disease must be treated through
more intricate methods.
• Obliteration of the internal opening is key to the success
of treatment
5
TREATMENT

• Oral metronidazole is a useful agent in the medical

management of fistula-in-ano in the population with
Crohn’s disease.

• The use of infliximab (Remicade, Centocor Ortho Biotech

Inc, Horsham, PA, USA), a monoclonal antibody to tumor
necrosis factor, has been shown to be effective in the
treatment of luminal Crohn’s disease.

5
FIBRIN GLUE

• The principle of its sealant properties is based on clot

formation
• Fibrin glue is a mixture of fibrinogen, thrombin, and
calcium ions, which when combined form a soluble clot,
because fibrinogen is cleaved into fibrin.
• A variable range of success has been achieved, from 31%
to 85%, because of the complexity of the disease and the
variation in tactics used to tackle the problem

5
FISTULA PLUG

• The biologic plug (Surgisis Anal Fistula Plug, Cook

Surgical, Bloomington, IN) is made of lyophilized porcine
small intestinal submucosa, which has an inherent
resistance of infection, generates no foreign body or
giant cell reaction, and is repopulated by host cell tissue
within 3 months.
• Its conical shape allows for added mechanical stability as
high pressures within the anal canal maintain the plug in
its proper position, avoiding dislodgement during
straining.

5
FISTULA PLUG

• Since introduction of the plug in early 2006, it has

achieved a wide range of success, reported between 14%
and 87%

5
ADVANCEMENT FLAP

• Surgeons devised the endorectal/endoanal advancement

flap as a sphincter-sparing method to treat complex anal
fistulas.
• It was believed that this would preserve continence
because there is no surgical division of the anal sphincter
complex.

5
SETONS

• Setons are a viable treatment option for high trans-

sphincteric fistulas, fistulas involving greater than half
the bulk of the sphincter complex, and anterior
transsphincteric fistulas in women.
• Numerous materials have been used for setons, including
nonabsorbable suture, Penrose drains, rubber bands,
vessel loops, silastic catheters, and ayurvedic thread
(kshara sutra).

5
Setons in the Management of Difficult
Fistulas
SETONS

• The 2 types of setons used are cutting setons, which

slowly incise through tissue, and noncutting setons,
which are primarily for drainage.

6
SETONS

• The seton is then placed through the fistula tract and

tightened at varying intervals (from a few days to every 2
weeks).
• There may be no need for further tightening if elastic
materials are used and are secured tightly at the time of
surgery.
• The time it takes to heal can range from 1 month to more
than a year.
• These patients require numerous follow-up visits, which
require tightening of the seton.

6
SETONS

• Noncutting (or draining) setons are typically used for

patients with chronic sepsis secondary to perianal
Crohn’s disease or acquired immune deficiency
syndrome, and in patients with severe anorectal sepsis.
• Although the risk of an impairment in continence is high
with seton fistulotomy, this technique is used for
complex, hard-to-treat fistulas

6
seton
Roeder knot
FISTULOTOMY

• Fistulotomy is still considered the standard by many

surgeons for low, simple anal fistulas, such as
submucosal, intersphincteric, and low trans-sphincteric
fistulas.
• Fistulotomy remains a major part of fistula treatment,
despite the high rate of incontinence that may be seen
postoperatively

6
NEWER METHODS OF TREATMENT

• The ligation of the intersphincteric fistula tract (LIFT)

procedure was first described in Thailand by Rojanasakul

7
NEWER METHODS OF TREATMENT

• Garcia-Olmo and colleagues investigated the use of

injected adipose-derived stem cells in the treatment of
complex anal fistulas. Their idea was based on
experience from plastic surgery of the use of these cells
in tissue repair

8
 VAAFT:Video Assisted Anal Fistula
• Visualization of the F.tract with the Fistuloscope

• Aim is to find the correct position of Internal Opening.

• A stapler to close the Internal opening.

• Fistuloscopy is done under irrigation & F.tract as well as all
granulation tissues are coagulated

• Total closure of the Internal opening with inserting the

Cyanoacrylate
VAAFT
SUMMARY

• The surgical management of fistula-in-ano is driven by

the amount of sphincter complex that is involved with
the tract, and the potential coexistence of Crohn’s
disease.
• The preferred method of management is dictated by
these factors
• Sphincter-sparing methods have lower success rates than
nonsphincter-sparing techniques, but come with little to
no risk of fecal continence

8
TERIMA KASIH
 Thank you !!!
• Refrences
> Bailey & Love's Short Practice of Surgery 25th
edition
>Manipal manual of surgery 3rd edition >SRB's
manual of surgery 4th edition